A Change Of Heart Over Pre-Op Exams

Nothing in podiatry school prepared me for my least favorite task in residency training, the complete preoperative history and physical examination. I chose podiatry partly because of the emotional and physical distance it afforded me with patients. We can do a lot for people’s feet without getting up close and personal. I’m a warm and friendly guy but I tend to get a little nervous when someone outside my family invades my 18-inch personal space barrier.
It’s impossible to do a complete physical examination without invading the patient’s personal space, thus having my own space invaded. I was nervous as a pimp in church each afternoon of my residency training when I got a list of five or six patients to examine.
Another thing that bothered me was playing doctor. I entered the patient’s room in scrubs and a white doctor coat with a stethoscope hanging out of my pocket and a flashlight and some tongue blades in my breast pocket. This image invited the eager patients to tell me about every little operation and medical problem they had ever had plus a few they were sure they had but which other doctors missed. I called this part the organ recital.
I always tried to do a thorough exam as a resident but tended to miss important signs due to inexperience. It always bothered me that the patients thought they were getting a real physical exam from a real doctor. I was quick to remind them I was a podiatry resident and they still should see their doctor for the usual yearly physical exam. My attendings and fellow residents thought this was bad for our image as podiatric physicians. I could have cared less about my image. I didn’t want any of these patients to skip their yearly exams with their own physicians, trusting that my exam was sufficient.
The end of my residency was a relief. I put my stethoscope away except for
occasional blood pressure readings. I kept the pen light for times when the lights went out in my office. I re-established my 18-inch comfort zone between me and my patients. I’m not a huggy, touchy-feely doctor. For the past 27 years, my patients and I have done well at a distance. Then things went and changed.
Many podiatrists were challenging the requirement for a pre-admission physical examination by an MD or DO for our patients. Managed care came along and the MDs and DOs were not being reimbursed for pre-op physicals. All of the sudden they didn’t think it would be so bad if the DPMs just did their own admission physicals. The Joint Commission on Accreditation of Healthcare Organizations was a little slow to buy into this change but last year, it caved in and podiatrists are now expected to do their own pre-admission exams.
Three months ago, the chickens came home to roost. The surgery committee and the hospital staff coordinator informed me I was to start doing my own exams for patients in ASA category I and II, those who are not sick or who are well controlled by medication.
I did not look forward to my first pre-op H&P after 27 years of comfortable distance. I let each patient know the H&P would be limited and would not include breast or urogenital examinations. I told them they could elect to have their family physicians do pre-op H&Ps. I also let them know they should not consider my examination their yearly physical.
Surprisingly, it has gone well. I dragged out my old stethoscope and replaced the dead batteries in my pen light. I reviewed Major’s text on physical diagnosis and I forgot about my 18-inch comfort zone.
My relationship and rapport with my surgical patients is better than ever. We schedule pre-op physicals one week before surgery, which gives the patient an opportunity for a 20-minute visit with me. Many bring up questions or fears about surgery and we discuss their concerns.
(Be aware of boundary issues. I have patients wear a paper gown and keep their underwear on. I always have a chaperone in the exam room, even with male patients. When the patient is an underage female, I ask her mother to stay in the room.)
I have postponed several surgeries due to hypertension and heart arrhythmias which were not previously detected. The internists and family doctors have been cooperative in managing these problems and returning the patients to my care.
I’m grateful to my podiatric colleagues who persevered to bring about this valuable change in the way we care for our patients.

Dr. McCord (pictured) is a Diplomate wtih the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.